Low risk drinking guidelines in Europe: results from RARHA survey E. Scafato, Istituto Superiore di Sanità, Italy

Low risk drinking guidelines in Europe: results from RARHA survey E. Scafato, Istituto Superiore di Sanità, Italy

Work Package Guidelines Co-led by the National Institute for Health and Welfare, Finland, and Istituto Superiore di Sanità, Italy Nearly 50 partners from 26 expert organizations based in 20 countries Surveys to update state of play and background papers to summarize science underpinnings regarding low risk drinking guidelines brief intervention practices standard drink concept guidance for young people Seeking broader views by means of Delphi surveys with public health and addiction experts experts on young people Online survey of consumer views Expert meetings Rome & Brussels 2014 Helsinki 2016 CNAPA 2014-2016 RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

The RARHA survey task 1 and 2 Low risk risk drinking guidelines in in Europe: results from RARHA survey 3

Standard Drink Low risk risk drinking guidelines in in Europe: results from RARHA survey 4

Standard Drink concept currently used 31 no. of Countries 0 19 2 9 1 19 2 10 1 30 21 2 1 7 RARHA Yes No missing data Country not investigated Yes No missing data Country not investigated Yes No missing data Country not investigated Yes No missing data Country not investigated Review WHO 2012 WHO 2013 OECD 2014 20 18 16 RARHA survey SD in grams of pure alcohol: 14 12 10 8 Mean= Median= 11 AUSTRIA (20) CROATIA (10; 14) CZECH REPUBLIC (16) DENMARK (12) ESTONIA (10) FINLAND (12) FRANCE (10) GERMANY (10; 12) GREECE (10; 16) HUNGARY (12; 14) ICELAND (8 ;12) IRELAND (10) ITALY (12) LATVIA (12) LITHUANIA (10) LUXEMBOURG (12) MALTA (8; 10) NETHERLANDS (THE) (10) NORWAY (12; 15) POLAND (10) PORTUGAL (10) ROMANIA (12) SLOVENIA (10) SPAIN (10) SWEDEN (12) SWITZERLAND (10; 12) UNITED KINGDOM (8) Low risk risk drinking guidelines in in Europe: results from RARHA survey 5

Standard Drink concept currently used in: Low risk risk drinking guidelines in in Europe: results from RARHA survey 6

Low Risk Guidelines (GL)/Recommendations (R) Low risk risk drinking guidelines in in Europe: results from RARHA survey 7

Low Risk GL/R issued 31 no. of Countries 0 20 10 0 1 12 8 10 7 24 20 3 1 7 RARHA 22 * 5 2 2 Yes No missing data Country not investigated Yes No missing data Country not investigated Yes No missing data Country not investigated Review WHO 2012 WHO 2013 OECD 2014 Yes No missing data Country not investigated Yes No missing data Country not investigated * Hungary and Lithuania have recommended limits Revision (yrs): Low risk risk drinking guidelines in in Europe: results from RARHA survey 8

WEEK low risk GL/R (in g) Low risk risk drinking guidelines in in Europe: results from RARHA survey 9

DAY low risk GL/R (in g) Low risk drinking guidelines in Europe: results from RARHA survey Low risk drinking guidelines in Europe: results from RARHA survey E. SCAFATO 2014 10

RARHA Low risk GL or R 4 3 2 5 17 10 5 2 Day D+W Week Guidelines 4 1 Day D+W Week Recommendations Guidelines (GL) Recommendations (R) Not investigated Countries Missing data No GL or R Low risk risk drinking guidelines in in Europe: results from RARHA survey 11

RARHA Low risk GL or R Average alcohol intake in a day not to be exceeded (grams of pure alcohol) 50 45 40 35 30 25 20 15 10 5 0 AUSTRIA (16) BELGIUM 50 45 40 35 30 25 20 15 10 5 0 BULGARIA Women AUSTRIA (24) Men CROATIA (20) BELGIUM CYPRUS BULGARIA CZECH REPUBLIC (20) CROATIA (40) DENMARK (12) CYPRUS ESTONIA (20) CZECH REPUBLIC (40) FINLAND (10) DENMARK (24) FRANCE (20) ESTONIA (40) GERMANY (12) FINLAND (20) GREECE (20-32) FRANCE (30) HUNGARY (18-21) GERMANY (24) ICELAND GREECE (30-48) IRELAND HUNGARY (24-48) ITALY (12) ICELAND LATVIA IRELAND LITHUANIA (20-30) ITALY (24) LUXEMBOURG (12) LATVIA MALTA (27) LITHUANIA (30-40) NETHERLANDS (THE) (10) LUXEMBOURG (24) NORWAY MALTA (36) POLAND (20) NETHERLANDS (THE) (20) PORTUGAL (10) NORWAY ROMANIA POLAND (40) SLOVAKIA PORTUGAL (20) SLOVENIA (10) ROMANIA SPAIN (20-25) SLOVAKIA SWEDEN SLOVENIA (20) SWITZERLAND (10-24 ) SPAIN (40) UNITED KINGDOM (16-24) SWEDEN SWITZERLAND (20-36) UNITED KINGDOM (24-32) Low risk risk drinking guidelines in in Europe: results from RARHA survey E. SCAFATO 2014 12

Average alcohol intake in a day not to be exceeded (g pure alcohol) Low risk drinking guidelines in Europe: results from RARHA survey Low risk drinking guidelines in Europe: results from RARHA survey E. SCAFATO 2014 13

Binge Drinking Low risk risk drinking guidelines in in Europe: results from RARHA survey 14

RARHA Binge Drinking GL or R 9 2 9 11 4 By gender 4 1 By gender and All 6 2 3 All consumers Guideline Recommendation No GL/Rec Not investigated Low risk risk drinking guidelines in in Europe: results from RARHA survey 15

RARHA Binge Drinking Maximum intake per drinking occasion (g pure alcohol) 90 80 70 60 50 40 30 20 10 0 90 80 70 60 50 40 30 20 10 0 AUSTRIA BELGIUM BULGARIA CROATIA CYPRUS CZECH REPUBLIC DENMARK (60) ESTONIA FINLAND (84) FRANCE GERMANY GREECE HUNGARY ICELAND IRELAND ITALY LATVIA (60) LITHUANIA (60-80) LUXEMBOURG (60) MALTA NETHERLANDS (THE) NORWAY POLAND (60) PORTUGAL (60) ROMANIA SLOVAKIA SLOVENIA (50) SPAIN (60) SWEDEN SWITZERLAND (40-48) UNITED KINGDOM (8 SU) Men AUSTRIA BELGIUM BULGARIA CROATIA CYPRUS CZECH REPUBLIC DENMARK (60) ESTONIA FINLAND (60) FRANCE GERMANY GREECE HUNGARY ICELAND IRELAND ITALY LATVIA (40) LITHUANIA (40-80) LUXEMBOURG (60) MALTA NETHERLANDS (THE) NORWAY POLAND (40) PORTUGAL (50) ROMANIA SLOVAKIA SLOVENIA (30) SPAIN (40) SWEDEN SWITZERLAND (30-36) UNITED KINGDOM (6 SU) Women 90 80 70 60 50 40 30 20 10 0 AUSTRIA BELGIUM BULGARIA CROATIA CYPRUS CZECH REPUBLIC (80) DENMARK ESTONIA FINLAND (60-72) FRANCE (40) GERMANY (50) GREECE (4 SU) HUNGARY (72-84) ICELAND IRELAND (60) ITALY (72) LATVIA (60) LITHUANIA LUXEMBOURG (60) MALTA (36) NETHERLANDS (THE) NORWAY POLAND PORTUGAL ROMANIA (72) SLOVAKIA SLOVENIA SPAIN SWEDEN SWITZERLAND UNITED KINGDOM All consumers Low risk risk drinking guidelines in in Europe: results from RARHA survey 16

Young People GL or R 31 0 6 10 5 10 12 19 15 13 1 2 24 22 20 18 16 14 12 10 AUSTRIA BELGIUM BULGARIA CROATIA (18) CYPRUS CZECH REPUBLIC DENMARK (16) ESTONIA (18) FINLAND FRANCE GERMANY GREECE HUNGARY ICELAND IRELAND ITALY (18) LATVIA LITHUANIA LUXEMBOURG (16-18) MALTA NETHERLANDS (THE) (18) NORWAY POLAND (18) PORTUGAL (10-24 ) ROMANIA SLOVAKIA SLOVENIA (18) SPAIN (16) SWEDEN (18-20 ) SWITZERLAND UNITED KINGDOM (15) Yes No missing data Country not investigated Yes No missing data Country not investigated no. of Countries Yes No missing data Country not investigated WHO 2012 WHO 2013 RARHA Age (yrs) Low risk drinking guidelines in Europe: results from RARHA survey Low risk drinking guidelines in Europe: results from RARHA survey E. SCAFATO 2014 17

Older People GL or R 5 14 10 2 21 6 2 2 Yes No missing data Country not investigated WHO 2012 Yes No missing data Country not investigated RARHA Low risk drinking guidelines in Europe: results from RARHA survey Low risk drinking guidelines in Europe: results from RARHA survey E. SCAFATO 2014 18

Pregnancy/ Breastfeeding GL or R 31 no. of Countries 0 8 Yes 0 No 22 missing data 1 7 7 7 Country not investigated Yes No missing data 10 Country not investigated 7 Yes 0 No 24 missing data Country not investigated REVIEW Review WHO 2012 WHO 2013 RARHA 25 4 2 Yes No Country not investigated Low risk drinking guidelines in Europe: results from RARHA survey Low risk drinking guidelines in Europe: results from RARHA survey E. SCAFATO 2014 19

Other guidelines: Low risk drinking guidelines in Europe: results from RARHA survey 20

Consensus and differing views in RARHA Delphi survey on low risk drinking www.rarha.eu

Joint Action RARHA Work Package Guidelines 1 Starting Point Guidelines for limiting drinking in order to reduce risks of harm from alcohol are given in most EU countries. Lot of variation in the scope of guidelines, levels of drinking defined as low/high risk, and definitions of standard drink. May confuse consumers when information is accessible across borders on the internet, on product labels... May reduce the potential for effect of risk communication to reduce alcohol related harm. Working methods Background papers to summarize the scientific basis as well as current definitions and practices to enable informed discussion. Two Delphi surveys to identify points of convergence and potential for consensus: Issues around low risk drinking guidelines Guidelines for reducing alcohol-relate harm for young people Meetings for exchange between experts and dialogue with decision-makers. www.rarha.eu

Joint Action RARHA Work Package Guidelines 2 Co-leaders National Institute for Health and Welfare THL (FI) Istituto Superiore di Sanità ISS (IT) Further Task leaders Landschaftsverband Westfalen-Lippe LWL (DE) Health Service Executive HSE (IE) Eurocare (EU) Participants Actively involved or as followers 34 partners from 24 countries Delphi survey around low risk drinking In all 22 partners involved in the planning process Methodological support provided by two additional experts Core planning group comprising Marjatta Montonen & Pia Mäkelä / National Institute for Health and Welfare (FI) Emanuele Scafato & Claudia Gandin / Istituto Superiore di Sanità (IT) Sandra Coughlan /Health Service Executive (IE) Sandra Tricas-Sauras / Eurocare. www.rarha.eu

RARHA Delphi survey on low risk drinking The Delphi method Method developed for future forecasting and to provide material for decision making on complex issues. The Delphi process: survey of expert views in two or more rounds, with results fed back to respondents in between. Respondent anonymity to minimize the effect of speaker status and group dynamics. The process leads to some degree of consensus and helps identify topics on which positions differ. The expert panel First round: 51 experts based in 27 countries Second round: 41 experts based in 23 countries 4/5 participating in both rounds strong expertise in the alcohol field considerable input from broader public health Prevention primary secondary tertiary /universal /targeted /indicated www.rarha.eu

Topics of the low risk Delphi survey Drinking guidelines as a public health measure Conceptual clarification: purposes of drinking guidelines; low versus high risk; drinking over longer terms versus on single occasion Need for gender-specific and age-specific guidelines Methodological issues Scientific basis: use of mortality data; how to factor in morbidity and harms to others Communication aspects How to prevent unwanted effects; groups and situations where general guidelines do not apply; particular harms to highlight in risk communication Possibility to move towards common guidelines Desirability of a common definition of low risk drinking; how to set the threshold for low risk Practical aspects related to the labelling of alcoholic beverages Usefulness of a common definition of standard drink ; what health related information should be given on alcoholic beverage labels www.rarha.eu

Delphi results: Drinking guidelines as a public health measure 1 Would you be supportive or against providing the general population with "low risk" drinking guidelines? 25 20 15 10 Round 1 (N=40) Round 2 (N=39) 5 0 Totally supportive Somewhat supportive Undecided Somewhat against Totally against www.rarha.eu

Delphi results: Drinking guidelines as a public health measure 2 Rationale for communicating low risk drinking guidelines Consumers have the right to be informed about risks related to lcohol consumption It is the responsibility for governments to provide such information. The core message is about risk rather than safety. Guidelines are needed separately concerning drinking over longer periods of time drinking on a single occasion. Realistic expectations regarding effects Low risk drinking guidelines may help correct misconceptions Communication about low risk, high risk and single occasion drinking guidelines may contribute in the longer term to influencing attitudes and drinking patterns in the whole population. Drinking guidelines are just one tool in the portfolio of measures to curb alcoholrelated harm. www.rarha.eu

Delphi results: Drinking guidelines to whom and for what purpose The primary purpose of low risk guidelines is to inform rather than immediately change drinking patterns. Low risk drinking guidelines High risk drinking guidelines Inform alcohol consumers and others about alcohol related risks Draw all alcohol consumers attention to the risks that may be involved in their drinking habits Encourage at risk drinkers reduce the amounts they are consuming Single occasion drinking guidelines Injuries and social harms www.rarha.eu

Delphi results: Need for gender-specific drinking guidelines Should the guideline on what consitutes a "low risk" level of drinking be different for women and for men Round 1 (N=40) Round 2 (N=39) 30 25 20 15 10 5 Why different 0 Yes, the specification for low risk level should be different for women and men. Undecided No, the same specification of low risk level can be applied to women and men Why not the same Physical differences (BAC levels) Biological differences (mortality) Specific risks (breast cancer) Risk fo harm to the foetus Broad acceptance of gender difference Alcohol is harmful for humans Gender differences in risk are small Women are less prone to risky behaviour People adjust drinking according to effects Easier to communicate a single guideline www.rarha.eu

Delphi results: Need for age-specific drinking guidelines: young people Young people: Which age group/s, if any, should be covered by separate guideline/s? 18year olds 15 year olds 0 2 4 6 8 10 12 14 16 18 20 No low risk guidelines for young people 16 year olds 17 year olds 18 year olds 19 year olds 20 year olds 21 year olds 22 year olds 23 year olds 24 year olds 25 year olds No separate "low risk" guidelines for young people www.rarha.eu

Delphi results: Need for age-specific drinking guidelines: older people Is there a need for specific drinking guidelines for older people? For the age group 65 years and over Clear statement on the level of alcohol intake not to be exceeded General statement about greater vulnerability due to biological changes Specific risks to be highlighted Interference or interaction of alcohol with medication, in particular with central nervous system depressants. Comorbidities with alcohol use disorders or diseases that may increase the risk of alcohol related harm. Risk of injuries and accidents, including when driving. www.rarha.eu

Delphi results: Methodological issues There is consistent evidence of a causal impact of the volume of alcohol consumption on a number of diseases. Knowledge of causality and risks relating to alcohol needs strengthening. Reliability and validity of self-reports of alcohol consumption deserves further attention. Further reserch on heavy drinking patterns and the risk of alcohol related mortality and morbidity. At the moment, mortality data is the most usable measure of alcohol related health harm available for epidemiological analysis of risks. Morbidity data (e.g. DALYs) would bring added value but at the moment does not allow robust estimation of risk curves. Further research on dose-response relationship between alcohol consumption and morbidity. Quantifying harms to others would be useful background for formulating low risk guidelines. Further research may increase understanding of confounders and the relationship between alcohol consumption and health conditions but the main body of science in this area is likely to remain valid. www.rarha.eu

Delphi results: Communication aspects Points to highlight to prevent unwanted effects Low risk drinking does not mean no risk. The maximum for a single occasion does not mean that drinking up to that level is safe or that it is OK to drink that much every day. Occasional heavy drinking and daily drinking are both potentially harmful drinking patterns. At-risk groups or high-risk situations that call for caution Use of medications Mental health problems / other addictions / family history of alcohol dependence Situations where the safest option is not to drink at all During pregnancy / when driving / at work / in tasks that require concentration Particular harms to highlight Increased risk of cancer Risk of adverse effects on the family Positive effects of alcohol No messages or messages to correct misconceptions www.rarha.eu

Messages reharding alcohol and pregnancy Examples Avoid alcohol if pregnant or trying to conceive UK Chief Medical Officers guideline, January 2016: If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk. US Centers for Disease Control and Prevention s Vital Signs report, February 2016 About half of all US pregnancies are unplanned and, even if planned, most women do not know they are pregnant until they are 4-6 weeks into the pregnancy. - - - It is recommended that women who are pregnant or might be pregnant not drink alcohol at all. USA 1989 France 2007 UK 2007 www.rarha.eu

Delphi results: Health related information on alcoholic beverage labels 1 Consumers should obtain full information on alcoholic beverages The calorie content percentage of daily intake All ingredients additives, preservatives, colouring substances All allergens Other nutrients Consumers should be alerted to specific risks: alcohol consumption during pregnancy drink driving mixing alcohol with medications vulnerability of minors effects on the brain loss of self-control violence decreased perception of risk addictive nature of alcohol www.rarha.eu

Delphi results: Health related information on alcoholic beverage labels 2 Would it be useful from a public health perspective if warning messages about health or safety risks were required across the EU on alcoholic beverage packages and/or on alcohol advertisements? Round 1 (N=38) Round 2 (N=39) YES Consumer s right Coherent policy Information gaps Risks for others 40 35 30 25 20 15 10 5 NO Risks are known Too much info Too small font Campaigns better 0 Packages YES NO Adverts YES NO www.rarha.eu

Delphi results: Definiton of standard drink 35 30 25 20 15 10 5 0 Would you be for or against agreeing on a common definition of standard drink Totally in favour Round 1 (N=38) Somewhat in favour Undecided Round 2 (N=39) Somewhat against Totally against A common definition would widen the reach of consumer information campaigns while decreasing the possibility of misunderstanding Alternative approaches Give up scientific precision in public communication: limit your consumption to X drinks a day Display in grams pure alcohol the alcohol content of the bottle/can/box or of the serving on the price list. 40 35 30 25 20 15 10 5 0 Would you be for or against requiring alcoholic beverage labels to indicate in addition to the % abv the grams pure alcohol contained in the package Totally in favour Round 1 (N=38) Somewhat in favour Undecided Round 2 (N=39) Somewhat against Totally against www.rarha.eu

Delphi results: Moving towards common guidelines 1 Would you consider it desirable for European public health bodies to agree on a common concept of "low risk" drinking? 35 30 25 20 15 Round 1 (N=42) Round 2 (N=39) 10 5 0 Yes, a common concept would be desirable Undecided No, it would not be desirable www.rarha.eu

CONCLUSIONS SHARING THE RESULTS SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM RARHA - FINAL CONFERENCE Good practice principles for the use of low risk drinking guidelines as a public health tool Lisbon. 13/14 October. 2016

Towards a common concept More authority and credibility, clearer and stronger. A co-ordinated effort by European countries to promote low risk guidelines using the same definition would have a better chance of being accepted by the population. However, National drinking guidelines have been introduced without coordination or international guidance. The WHO does not set limits for alcohol consumption the ideal for health is not to drink at all. Drinking guidelines in some countries have a long history. Public health bodies in some countries have chosen not to issue guidelines on low risk drinking. To effectively communicate low risk drinking guidelines to the population, pre-existing information needs and perceptions need to be taken into account. Nevertheless, a move towards a more aligned approach is possible Adopting the cumulative lifetime risk of death due to alcohol as a common metric for assessing the risks from alcohol. Applying the good practice principles suggested by Joint Action RARHA. RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Good practice principles for drinking guidelines Principles Drinking guidelines are not normative but informative. The core message is about risk, not safety. Guidelines should convey evidence-based information on risks at different levels of alcohol consumption, correct misconceptions about the likelihood of positive or negative health effects of alcohol, and help alcohol consumers to keep the risk of adverse outcomes low. Agreeing on a European code on alcohol Set of core messages applicable across diverse populations. To amplify the core message to alcohol consumers and the society at large. To provide a common reference and support for national action. RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Good practice principles for drinking guidelines Components Daily drinking and occasional heavy drinking should both be highlighted as potentially harmful drinking patterns. Advice to limit average consumption over a longer period of time. Advice to limit the amount drunk on any single occasion. Advising equally low consumption levels for men and women, while highlighting genderspecific factors in verbal communication, should be considered. Guidance for healthy adults should be accompanied by guidance for various age groups, in particular for older people. Advice should be provided concerning alcohol consumption in high-risk situations and at-risk groups. While the focus in drinking guidelines is on health risks, it should be communicated that limiting alcohol consumption and avoiding drunkenness also reduces the risk of social harms to the drinker and to others. RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Good practice principles for drinking guidelines Key messages Not drinking at all is the safest option in pregnancy, childhood and adolescence when driving, at work or engaged in tasks that require concentration. High-risk situations include taking a medication that may interact with alcohol. At-risk groups include people with other addictions, mental health problems or family history of alcohol dependence. Advice for older people should highlight risk of adverse interactions with medications, co-morbidities and injuries. Specific harms to highlight include increased risk of cancer, high blood pressure, addiction, depression, adverse effects on the brain, overweight and adverse effects on the family. As low risk drinking guidelines are based on averages across populations, any individual should also take into account their own characteristics and particular situation. RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Support measures at European and national level Legislating for health relevant information on alcoholic beverage labels. Ingredients and nutrition values The amount of calories in the bottle or can The amount of pure alcohol in the bottle or can, in grams of ethanol Message/s on the health and safety risks related to alcohol consumption Requiring information on health and safety risks on alcoholic beverage packages and alcohol advertisements. Alcohol consumption during pregnancy; Vulnerability of minors Drink driving; Mixing alcohol with medications Effects on the brain; Addictive nature of alcohol Loss of self-control; Violence; Decreased perception of risk For effectiveness, health and safety messages should be: Rotating designed to fill in gaps in information Clear and powerful Highly visible, of sufficient size, placed on the front of containers RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Support measures at European and national level Applying and enforcing an age limit of minimum 18 years for the sale and serving of any alcoholic beverages. Organized and regular enforcement Training for servers and retailers Efforts to enhance public awareness and support for compliance with age limits Effective use of sanctions suspension of alcohol license, closure order. For promoting awareness and enforcement, an integrated alcohol policy with a combination of structural and individual prevention measures is needed rather than isolated actions. Supporting in particular primary health services to identify at-risk drinkers and offer advice to reduce high-risk drinking. RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Experts would welcome a common concept of low risk drinking Would you consider it desirable for European public health bodies to agree on a common concept of "low risk" drinking? 35 30 25 20 15 Round 1 (N=42) Round 2 (N=39) 10 5 0 Yes, a common concept would be desirable Undecided No, it would not be desirable RARHA - FINAL CONFERENCE SHARING THE RESULTS LOOKING HOW TO REDUCE ALCOHOL RELATED HARM

Low risk drinking guidelines in Europe: results from RARHA survey Thank you for your attention